APPLICATION FOR FINANCIAL ASSISTANCE FOR EYEGLASSES
PLEASE PRINT AND COMPLETE IN FULL
MAIL TO: Chesterfield Lions Club Eyesight and Hearing Committee Optionally sign, scan and email to: PO BOX 151, Chesterfield NH 03443-0151 Chesterfieldlions@gmail.com
|
AGENCY AND PERSON REFERRING (IF ANY) |
PHONE AND EMAIL |
|
APPLICANT'S NAME |
DATE OF BIRTH |
SOCIAL SECURITY NUMBER |
||||
|
ADDRESS |
CITY/TOWN/STATE |
ZIP |
HOME PHONE |
|||
|
Email (Optional for faster processing) |
MONTHLY RENT OR MORTGAGE PAYMENT |
|||||
|
NAMES AND AGES OF DEPENDENT CHILDREN IN HOME |
||||||
|
EMPLOYER |
ADDRESS |
PHONE |
||||
|
MONTHLY INCOME |
POSITION AND DUTIES |
|||||
DO YOU RECEIVE INCOME FROM ANY OF THE FOLLOWING SOURCES?
|
SSI OR SSDI YES / NO (CIRCLE ONE) |
AMOUNT |
FOOD STAMPS YES / NO (CIRCLE ONE) |
AMOUNT |
|
SOCIAL SECURITY YES / NO (CIRCLE ONE) |
AMOUNT |
WELFARE YES / NO (CIRCLE ONE) |
AMOUNT |
|
VA DISABILITY YES / NO (CIRCLE ONE) |
AMOUNT |
OTHER (LIST) |
AMOUNT |
|
IF UNEMPLOYED, DO YOU RECEIVE UNEMPLOYMENT COMPENSATION? YES / NO (CIRCLE ONE) ARE YOU ACTIVELY SEEKING EMPLOYMENT THROUGH THE UNEMPLOYMENT OFFICE? YES / NO |
AMOUNT |
DOES ANYONE IN YOUR FAMILY RECEIVE INCOME FROM ANY OF THE FOLLOWING SOURCES? PLEASE LIST THEIR NAME AND RELATIONSHIP BELOW.
|
SSI OR SSDI NAME |
AMOUNT |
FOOD STAMPS NAME |
AMOUNT |
|
SOCIAL SECURITY NAME |
AMOUNT |
WELFARE NAME |
AMOUNT |
|
VA DISABILITY NAME |
AMOUNT |
UNEMPLOYMENT COMPENSATION NAME |
AMOUNT |
HAVE YOU OR ARE YOU RECEIVING ASSISTANCE FROM ANY AGENCY FOR EYE CARE OR HEARING? YES / NO
|
AGENCY NAME |
DATE |
ARE YOU RECEIVING MEDICAL CARE THROUGH MEDICAID? YES / NO (CIRCLE ONE)
PLEASE COMPLETE BOTH PAGE 1 AND PAGE 2 OF THIS APPLICATION
PLEASE USE THE SPACE BELOW TO LIST MONTHLY OBLIGATIONS WHICH MAKE IT UNAFFORDABLE FOR YOU TO PAY FOR YOUR EYESIGHT CARE. EXAMPLES MIGHT BE SUPPORT, CHILD CARE, LOAN PAYMENTS, MEDICAL COSTS OR OTHER.
PAYMENT $
PAYMENT $
PAYMENT $
PAYMENT $
 |
WHAT ASSISTANCE DO YOU NEED? EYE EXAM YES / NO NAME OF DOCTOR YOU WISH TO SEE?
FRAME YES / NO LENSES YES / NO CHECK BOX IF NO PREFERENCE
Our commitment is for single vision lenses or for bifocal lenses, or more expensive glasses if medically necessary. No cosmetic tint or gradient lenses will be approved by the Lions Club. If you want special frame or special lenses you will be required to pay the entire cost of the exam and glasses .
REMARKS: YOU MUST DESCRIBE IN DETAIL WHY YOU NEED ASSISTANCE FROM CHESTERFIELD LIONS CLUB:
 |
 |
 |
 |
AUTHORIZATION AND RELEASE
This authorization and release constitutes my consent to disclosure of any relevant or necessary information or records to any duly authorized official of Chesterfield Lions Club by any person, corporation, agency or association concerning my character, employment, financial status, debts, income, financial assistance or medical status for determination of my eligibility for financial assistance by Chesterfield Lions Club. This authorization includes, but is not limited to, banks or other financial institutions, present and former employers, the State of New Hampshire Department of Employment Security, Social Security Administration, Department of Welfare, Food Stamps Program, Veterans Administration, Workman's Compensation and Medical organizations.
This authorization is executed with full knowledge and understanding that Chesterfield Lions Club will take measures to protect the aforementioned information against unauthorized disclosure to any parties not having a legitimate need for it. As deemed appropriate by officials of Chesterfield Lions Club, I authorize that this information be provided to other Lions clubs in order to determine my eligibility for assistance from them. I hereby release the aforementioned persons, corporations, agencies, associations, organizations and their employees, agents and representatives from any and all liability for damages resulting from inadvertent release of information or from a decision by Chesterfield Lions Club not to financially assist me on account of compliance or any attempts at compliance with this authorization except for any damages resulting from knowingly providing false or misleading information or records on me.
A copy of this authorization shall be as effective and valid as the original. This authorization shall be effective for six months from the date it is signed.
Applicant's Signature: Date
Mail to Chesterfield Lions Club Eyesight and Hearing Committee, PO Box 151, Chesterfield NH 03443-0151
Rev. April 30, 2015
